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No Yes (If yes, list names of ALL (Rochester Community and Technical College)

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Summer 2019-2020 Postsecondary Child Care Grant Program Application – Rochester Community and Technical College
1. Name (Last, First, Middle):
2. Student School ID:
3. Student’s Email Address:
4. Permanent Home Address:
5. City, State, Zip Code:
6. County of Residence:
7. Telephone Number:
8. Number of children 12 years of age or younger
receiving child care:
9. Number of children with a disability 14 years of age
or younger receiving child care:
10. Are you and/or any of your dependents currently receiving MFIP benefits?
No Yes (If yes, list names of ALL MFIP recipients and attach documentation from county social services.)
11. Are you or the other parent receiving child care assistance from some other source? (See instructions.)
No Yes (If, yes, please identify source and attach documentation of assistance you are receiving.)
Caseworker’s phone number:Caseworker’s name:_____________________________ __________________
12. Indicate the number of credits for which you intend to register:
(There is a 6 credit minimum requirement for this program.) Summer Term ___________
STUDENT CERTIFICATION
• I understand and accept the obligation to provide a written report to the school of any changes in information
provided on this application within 10 days of the change. Changes may include, but are not limited to, my
enrollment, family size, family income, receipt of MFIP, Basic Sliding Fee or Transition Year benefits, hours of child
care, changes in provider, or provider rates, etc. I understand that failure to report any changes within 10 days will
result in cancellation and possible repayment of any Postsecondary Child Care Grant.
• I understand that the Postsecondary Child Care Grant must be used to pay my child care provider and that the
award is subject to repayment and/or cancellation if used for other purposes. I agree to furnish receipts from my
child care provider if requested by the school or the Office of Higher Education staff.
• I give permission to the Office of Higher Education and any school I attend to share information regarding the
Postsecondary Child Care Grant with my child care provider(s) and to verify the information on this application. I
also give my provider permission to verify the information in the provider’s section, when contacted by the school
or the Office of Higher Education staff and I understand that my application will be on hold until the provider
information has been verified.
• I give permission to the county social service agency to release to the school or the Office of Higher Education the
amount and terms of any MFIP, Transition Year or Basic Sliding Fee child care benefits I receive from July 1, 2019 to
September 30, 2020. I give permission to the school and the Office of Higher Education to report my child care
award to my county social service agency if I receive MFIP, Transition Year benefits or Basic Sliding Fee child care
assistance during this academic school year.
• I declare that the other parent or legal guardian of my child/children is not capable or available to care for my
child/children during the hours for which I have requested an award from the Postsecondary Child Care Grant
Program.
• I understand that if I withdraw or reduce my enrollment after receiving a Postsecondary Child Care Grant, all or a
portion of the grant will need to be repaid to my college.
• I certify that the information on this application is true and correct and I promise to provide additional
documentation if requested. I understand that this form is used to establish eligibility for the Postsecondary Child
Care Grant Program and that if I purposely give false or misleading information on this form, I may be subject to a
fine, a prison sentence, or both and such action may result in the forfeiture or repayment of future awards from
this program.
Student’s Signature - By signing here I understand and agree to the above mentioned guidelines. Date (month/day/year)
Student Name:
Student School ID:
Provider must complete entire section for services provided May 26, 2020 through August 6, 2020. If services will not be provided
for this entire timeframe, provide the date services will be utilized: Start Date___________ End Date___________
Child’s Full Name
Age
Child’s Date
of Birth
Total Hours
Child Care
Provided Per
Week
Amount Charged Per Child
Rate Type Charged (check one box)
Hourly Rate
Weekly Rate
Date Day Care
Started
$
$
$
$
Please list child care assistance paid to provider from other sources such as
Basic Sliding Fee, Early Childhood Scholarship, Transition Year, other parent
receiving discounted rate, child care scholarships or any other assistance
programs, etc.
Source:_______
Source:_______
$_______
$_______
Child_______
Child_______
Child Care Center / Provider’s Printed Name
Relationship to Student (if any)
Provider’s Street Address
City, State, Zip Code
County Provider Located
Provider’s Phone Number
Land Line: ( ) Cell: ( )
Provider’s Email Address
Check all that apply:
I am a licensed home child care provider. License number: ____________________________
I represent a licensed child care center. License number: ______________________________
I represent a latch-key program which has a contract with a school district to provide child care for school age children.
I represent a child care center which is legally exempt from licensure. (YMCA, tribal daycare)
I am at least 18 years of age. Under the exempt status I will only care for this family’s children, besides my own and I do not
PROVIDER CERTIFICATION
• I certify that the information provided in the provider section is true and correct and that if I purposely give false or
misleading information on this form, I may be subject to a fine, a prison sentence, or both and such action may result
in the forfeiture of future awards from this program.
• I promise to provide additional documentation if necessary, including confirming the above information when
contacted by Office of Higher Education staff or the college financial aid administrator. I also grant permission to
Office of Higher Education or school auditors to review my financial records to verify receipt of Postsecondary Child
Care Grant funds.
• Applies only to unlicensed child care providers. I give permission to the Office of Higher Education or the school to
report the amount of the student’s Postsecondary Child Care Grant to the Internal Revenue Service or the Department
of Revenue as taxable income to the provider, when requested.
• I understand that I cannot charge a Postsecondary Child Care Grant recipient a higher rate for services than the rates
charged to other clients who are not recipients. I understand that if I purposely give false or misleading information on
this form, I may be subject to a fine, prison sentence, or both.
• I understand the obligation to immediately report any changes to the information provided in the above chart to the
student’s financial aid administrator. This includes informing the school if I am no longer providing child care services
for the student’s children.
Provider’s Signature - By signing here I understand and agree to the above mentioned guidelines. Date (month/day/year)
Please report any changes to the student’s college financial aid administrator using this contact information:
Renea Kispert, Financial Aid Assistant / Rochester Community & Technical College / 851 30
th
Avenue SE, Rochester, MN 55904
1-800-247-1296 ext 7337 / 507-285-7337 / renea.kispert@rctc.edu
2019-2020 Postsecondary Child Care Grant Program Application Instructions – Rochester Community and Technical College
IMPORTANT: Read instructions before completing application. Incomplete applications will not be processed.
Your Free Application for Federal Student Aid (FAFSA) must be complete before a Child Care Grant Award can be
determined. FAFSA applications can be completed on-line at www.fafsa.gov Funding for the Child Care Grant is
awarded on a first serve basis.
The maximum full-time Postsecondary Child Care Grant award for a full-time undergraduate student, 15 credits,
is $3,000, for each eligible child per nine-month academic year. Students are able to receive an extra term of
eligibility for summer term attendance. Annual awards will be divided evenly into term installments and
disbursed to recipients each semester. The amount of the full-time term award will be decreased for
undergraduate students taking 6-14 credits. Assistance may cover up to 40 hours of child care per week for each
eligible child. For a maximum home care cost of $5 an hour, and a maximum center care cost of $10 an hour.
The institution may increase the amount shown on the maximum award chart by ten percent to compensate for
higher infant care rates charged by some providers. The school may choose to make payments more frequently
or to pay the provider directly. Office of Higher Education staff or the college financial aid administrator will
contact child care providers to verify the information provided on the application.
In order to be eligible, a recipient must:
1. be a Minnesota resident or the applicant’s spouse meets the MN resident definition (see definition
below), including undocumented students who qualify under the MN Dream Act;
2. not be receiving benefits from the Minnesota Family Investment Program (MFIP);
3. must be income eligible (your college financial aid office has a chart showing qualifying income
guidelines);
4. be pursuing a non-sectarian program or course of study that applies to an undergraduate, graduate or
professional degree, diploma, or certificate;
5. have a child 12 years of age or younger, or 14 years of age or younger with a disability, needing child
care service on a regular basis;
6. be enrolled at least half time, undergraduate students taking at least six credits or graduate students
taking at least one credit per quarter, semester, or the equivalent;
7. be in good standing and making satisfactory academic progress;
8. not be receiving tuition reciprocity;
9. not be in default on a student loan or, if in default, have made satisfactory arrangements to repay the
loan with the holder of the note;
10. either has not earned a baccalaureate degree and has been enrolled full time less than ten semesters or
the equivalent, or has a baccalaureate degree and has been enrolled full time less than ten semesters or
the equivalent in a graduate or professional degree program; and
11. a student who withdrew from college during a term because you were called up for active military
services after December 31, 2002, or for a major medical illness may be eligible for an additional term
award, please provide the necessary documentation to your college financial aid administrator.
2019-2020 Postsecondary Child Care Grant Program Application Instructions – Rochester Community and Technical College
Minnesota resident is:
1. a student who has resided in MN for purposes other than postsecondary education for at least 12
consecutive months without being enrolled at a postsecondary institution for more than five
undergraduate or one graduate credits in any term; or
2. a dependent student whose parent or legal guardian resided in MN at the time the 2019-2020 FAFSA
was completed; or
3. a student who graduated from a MN high school, if the student was a resident of MN during the
student’s period of attendance at the MN high school and the student is physically attending a MN
campus; or
4. a student who, after residing in the state of MN for a minimum of one year, earned a high school
equivalency certificate in MN; or
5. a student who is a member (or spouse/dependent of a member) of the armed forces of the United
States stationed in MN on active federal military service as defined in section 190.05, subdivision 5c; or
6. a spouse or dependent of a veteran, as defined in section 197.447, if the veteran is a MN resident; or
7. a student (or spouse of) who relocated to MN from an area that is declared a presidential disaster area
within 12 months of the disaster declaration, if the disaster interrupted the person’s postsecondary
education; or
8. a student defined as a refugee under United States Code, title 8, section 1101 (a)(42), who, upon arrival
in the United States, has moved to MN and has continued to reside in MN.
9. a student eligible for resident tuition under section 135A.043; or
10. an active member, or a spouse or dependent of that member, of the state’s National Guard who resides
in Minnesota or an active member, or a spouse or dependent of that member, of the reserve component
of the United States armed forces whose duty station is located in Minnesota and who resides in
Minnesota; or
11. a student whose spouse meets the definition of a Minnesota resident.
Question #9 on application – Child with a disability is: A child who has a hearing impairment, blindness,
visual disability, speech or language impairment, physical disability, other health impairment, mental
disability, emotional/behavioral disorder, specific learning disability, autism, traumatic brain injury, multiple
disabilities, or deaf/blind disability and needs special instruction and services, as determined by the
standards of the commissioner, is a child with a disability.
A child without a disability is: A child with a short-term or temporary physical or emotional illness or
disability, as determined by the standards of the commissioner, is not a child with a disability.
Question #11 on application – Other sources of child care funding: Answer “yes,” if you are receiving child
care funding from another source. Examples are: the child’s other parent is receiving the Postsecondary
Child Care Grant, your employer is helping to pay your child care costs, you receive Basic Sliding Fee child
care assistance from the county, you receive an Early Childhood scholarship, you receive any other
assistance to help pay for daycare costs, other parent is receiving any of the above or a discounted day care
rate, or your ex-spouse is required to cover a portion of child care costs per divorce decree, etc.
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Completed 19 September 2020

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